Fraud and Abuse Prevention Program
Hardship Agreement & Medically Indigent Policy
In consideration of my particular medical needs and care expenses to be incurred solely based on such medical needs, and my
financial ability to pay for such recommended medical services without or even with applicable insurance coverage, and with
understanding and agreement that I am personally financially and legally obligated o and responsible for any and all professional
actual total charges regardless of any applicable insurance coverage, I hereby declare that I have financial difficulty to pay for
part or all expenses because of the following:
☐ Low or a fixed income
☐ Without any or applicable insurance for treatment at this clinic
☐ With applicable insurance but still medically indigent (see below)
More importantly, I declare that without following indigent assistant, seeking for and continuing with medically appropriate and
important health care would be impossible for me or would make me indigent if I were forced to pay full charges for my
medically necessary care expenses. I also declare that I personally requested for such indigent assistance only after I was fully
informed of my important medical treatment options and necessity solely based on my particular medical needs and availability of
this provider Indigency Policy:
“Nothing in the Centers for Medicare & Medicaid Services’ (CMS’) regulations, Provider Reimbursement
Manual, or Program Instructions prohibit a healthcare provider from waiving collection of charges to
any patients, Medicare or non-Medicare, including low-income, uninsured or medically indigent
individuals, if it is done as part of the healthcare provider indigency policy.”
“By “indigency policy” we mean a policy developed and utilized by a healthcare provider to determine
patients’ financial ability to pay for services. By “medically indigent,” we mean patients whose
health insurance coverage, if any, does not provide full coverage for all of their medical expenses
and that their medical expenses, in relationship to their income, would make them indigent if they were
forced to pay full charges for their medical expenses."
I specifically request under this provider indigency policy for the following discount assistance for the specific time
periods from :
______/________/_______ to _______/________/________:
☐ Waiving collection of deductible
☐ Waiving collection of co-pays/encounter fees
☐ Waiving collection of co-insurance
☐ Waiving collection of partial ________________________
!
Patient’s Printed Name______________________________________
!
Patient Number____________
Patient’s Signature_________________________________________
Date______________
Our indigency discount is no different than any preferred provider organization discounts from commercial insurers in compliance
with all applicable federal and state laws with respect to indigency assistance without any routine waiver of sharing, advertising,
or solicitation, for underinsures or uninsured patients. Once indigency is determined, collection is no longer undertaken with
regard to the patient for the forgiven amount without waiving any patient financial and legal obligation or responsibility to the
provider’s actual total charges AND patient’s right and eligibility, assigned to the provider, to claim for the reimbursement, under
the health plan coverage, based on the provider on the provider’s actual total and reasonable charges in accordance with Provider’s
Company Indigency Policy, as the Indigency determination itself is a good effort to collect, and hospitals or doctors are NOT
required under any federal or state laws, Medicare, ERISA, & PPACA, to take low-income, medically indigent, uninsured or
underinsured patients to court, garnish their wages or seize their homes, or send claims out to collection agency when those
patients don’t or can’t pay their hospital or doctor bills.
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